Charles L. Curry

Preparticipation echocardiographic screening for cardiovascular disease in a large, predominantly black population of collegiate athletes.

Sudden death in young competitive athletes is most commonly due to underlying cardiovascular disease. Echocardiography has the potential to identify structural cardiovascular abnormalities, such as hypertrophic cardiomyopathy (HC), that have been incriminated in such events. In this study, echocardiography (2-dimensional and M-mode) was used as a primary screening test to assess 265 Howard University collegiate athletes for cardiovascular disease; 262 (99%) were black. Most athletes (234, 88%) had no definitive echocardiographic evidence of HC or other major cardiovascular diseases, but 30 (11%) had mitral valve prolapse, and 1 other athlete had a small atrial septal defect. In addition, 4 athletes were identified as having mild systemic hypertension. Most athletes (236 of 265) showed normal left ventricular wall thickness of less than or equal to 12 mm, but an important minority (29, 11%) had maximal ventricular septal thicknesses of greater than or equal to 13 mm that could not always be distinguished (by morphology alone) from mild anatomic expressions of nonobstructive HC. Based on this experience, preparticipation athletic screening using echocardiography as the primary test does not appear to be justified on a cost-effective basis. In addition, the substantial minority of subjects with increased wall thickness made clinical interpretation of the echocardiographic findings difficult in individual athletes.

Discordance in degree of right and left ventricular dilation in patients with dilated cardiomyopathy: recognition and clinical implications.

OBJECTIVES The purpose of the present study was to assess the influence of variations in the relative degree of dilation of left and right ventricular chambers on the clinical outcome of patients with dilated cardiomyopathy. BACKGROUND Dilated cardiomyopathy, a primary myocardial disease characterized by ventricular dilation and systolic dysfunction, is generally associated with a poor prognosis. However, considerable variability has been observed in the clinical course and the morphologic and hemodynamic features in individual patients. METHODS We evaluated 67 consecutive patients with dilated cardiomyopathy and without evidence of ischemic or primary valvular heart disease. On the basis of diastolic ventricular chamber area measurements obtained by echocardiography, patients were classified into two groups: 38 patients with a relatively equal degree of left and right ventricular dilation (LV congruent to RV) and 29 patients with predominant and disproportionate dilation of the left ventricle (LV > RV). RESULTS The 67 patients ranged in age from 19 to 81 years (mean 56); 49 (73%) were male. The two subsets of patients with dilated cardiomyopathy did not differ with regard to age, left ventricular diastolic dimension, wall thickness and mass or ejection fraction. However, patients in the LV congruent to RV group showed more severe mitral and tricuspid regurgitation by Doppler echocardiography than did those in the LV > RV group (p = 0.01 for mitral and 0.004 for tricuspid regurgitation). Over the follow-up period of 2 to 60 months (mean 28), there were 19 deaths. Survival in the LV > RV group was significantly better than in the LV congruent to RV group (p = 0.03). CONCLUSIONS Patients with dilated cardiomyopathy represent a heterogeneous group with regard to both clinical outcome and the relative degree of left and right ventricular chamber dilation. Patients in the LV > RV subset appear to have better overall survival and less severe mitral and tricuspid regurgitation than do patients in the LV congruent to RV subset. Longitudinal studies are needed to determine whether these morphologic subsets in fact represent a continuum within the disease spectrum of dilated cardiomyopathy.

Echocardiographic observations in opiate addicts with active infective endocarditis

Echocardiographic observations are described in 25 opiate addicts with active infective endocarditis involving apparently previously normal valves. Infective endocarditis was isolated to the tricuspid valve in 11 patients, involved both right- (tricuspid valve) and left-sided valves in 7 and was isolated to the left-sided valves in 7 (mitral valve in 6). Twenty patients (80%) had tricuspid valve regurgitation, 12 had mitral regurgitation, 3 had aortic regurgitation and none had pulmonary valve regurgitation. Considering the 75 cardiac valves (excluding the pulmonary) in the 25 patients, echocardiographic abnormalities consistent with active infective endocarditis were detected in 26 (74%) of the 35 clinically incompetent valves but in none of the 40 competent valves. Comparison of the 20 incompetent tricuspid valves with the 12 incompetent mitral valves indicated that (1) the echocardiogram was less sensitive in detecting tricuspid valve lesions, (2) rupture of tricuspid valve chordae tendineae was absent or not detectable, and (3) tricuspid valve vegetations tended to be larger.

Cardiovascular effects of dobutamine in severe congestive heart failure

The effects of continuous infusion of dobutamine 5 to 15 microgram/Kg./min. were studied in 17 patients using right heart catheterizations, echocardiography, and/or the Systolic Time Intervals. HR increase was dose-related, but insignificant (p less than 0.05) rate increase was obtained at infusion rates below 15 microgram/Kg.)min. C.O. increased from 2.9 +/- 0.7 to 5.0 +/- 1.2 liters/min. (p less than 0.001), and the stroke volume from 30 +/- 6 to 49 +/- 14 ml./min. (p less than 0.005). The mean BP did not change, P.A.W.P. decreased from 30 +/- 7 to 20 +/- 8 mm. Hg (p less than 0.001) and R.A.P. from 20.0 to 12.0 mm. Hg (p less than 0.005). The P.E.P.I. decreased from 160.93 +/- 54.91 to 133.4 +/- 28.7 msec. (p less than 0.050). Echo-determined mean VCf increased from 0.387 +/- 0.14 to 0.537 +/- 0.13 cm. (p less than 0.010), diastolic diameter did not change significantly, but the end systolic diameter decreased from 6.020 +/- 0.69 to 5.750 +/- 0.70 cm. (p less than 0.025). During a mean infusion period of 75 hours, the only side effects noted were transient nausea and/or vomiting at 15 microgram/Kg./min. dose range in two patients, and multifocal P.V.C.s following 68 hours of infusion in another patient. It is concluded that in the dose range of 5 to 15 microgram/Kg./min., dobutamine is well tolerated and is a very potent inotropic agent with only minor effects on the heart rate and blood pressure.

Evidence of Higher Ethynylestradiol Blood Levels in Human Hypertensive Oral Contraceptive Users

These studies were designed to investigate the differences in blood plasma levels of ethynylestradiol (EE2) in women who developed hypertension while taking combined estrogen and progesterone oral contraceptives (OCs) and in normotensive OC users. Blood samples were collected in heparinized tubes 10 hours after OC ingestion, the plasma was separated, and EE2 was measured by radioimmunoassay. The results showed significantly higher plasma levels of EE2 in the hypertensive OC users as compared with the levels in normotensive OC users (P less than 0.01). In another study, blood samples from hypertensive and normotensive OC users were obtained for 3 consecutive days at fixed intervals following OC ingestion, and plasma levels of EE2 were measured. The results showed consistently higher EE2 blood levels during this 3-day period in the hypertensive subjects (P less than 0.01). It is postulated that the higher blood levels of EE2 in hypertensive OC users result from either decreased metabolism or excretion of synthetic estrogens.

Task Force III: Major Demographic and Epidemiologic Trends Affecting Adult Cardiology

cmm br r eporared from rbr genwol wdrrarional issrrrs srrrroanding provision of medical cm’. To conceive of manpower as a technical matter merely sidesteps the basic diffcrenccs in va!ues underlying policy choices. The resulting confusion bewecn means and ends Iewes decisions vulnerable to the influence of values that remain both unexpressed and unexamined. If a smte follows federal practices in manpower policy, these unexpressed values are likely to be federal values rather than the state’s.

Coronary artery disease in blacks: Risk factors

The current literature indicates that of the major risk factors for coronary artery disease (CAD), United States blacks and whites have similar rates for cigarette smoking and cholesterol levels. The prevalence of diabetes mellitus is higher in black females than white females. Both black males and females have higher prevalence rates for hypertension. These differences in risk factors between blacks and whites in spite of similar degrees of CAD suggest that the relative importance of specific risk factors might differ between the two racial groups. Research is needed to determine if there are protective factors in blacks (e.g., high-density lipoprotein cholesterol) and/or previously unrecognized risk factors (e.g., diuretic-induced lipid abnormalities) that may be playing a major role in the epidemiology of CAD in the black population.

Regression of left ventricular hypertrophy in patients with essential hypertension: Results of 6 month treatment with indapamide

Left ventricular hypertrophy (LVH) is a major risk factor for cardiovascular morbidity in hypertensive patients. The effects of diuretics on LVH have raised controversies, but recent studies suggest that diuretics are able to reduce LVH in hypertensive patients, mainly through a reduction in ventricular diameter. The present multicenter open study was designed to test the effects of indapamide, a widely used nonthiazide diuretic, on LVH in patients with essential hypertension. Patients had to have mild-to-moderate essential hypertension (supine diastolic blood pressure [sDBP] 95 to 115 mm Hg) with echocardiographic evidence of LVH (left ventricular mass index [LVMI] > 130 g/m2 for men and > 110 g/m2 for women). After a 2 week placebo run-in period, eligible patients underwent a 6 month treatment with 2.5 mg indapamide daily. All echograms were performed by the same investigator before and after 6 months of indapamide. Clinical and biological acceptability and quality of life (visual analog scale) were also studied. One hundred and thirty patients were included in the study and 112 completed the trial. Indapamide induced a significant reduction i systolic and diastolic blood pressures. Indapamide induced a marked reduction in posterior wall thickness (from 12.1 +/- 2.0 to 11.2 +/- 1.6 mm) and in interventricular wall thickness (from 12.7 +/- 1.7 to 11.8 +/- 1.9 mm; each P < .001) and a slight decrease in left ventricular diameter (P = .049). This resulted in a 13% reduction in LVMI (from 161.9 +/- 37.9 to 140.7 +/- 33.8 g/m2, P < .001). Left ventricular fractional shortening remained unchanged. There was no significant relation between changes in LVMI and changes in systolic, diastolic, or mean blood pressure. No significant adverse clinical or biological effects were reported during the study. The increased score of the visual analog scale indicated that overall well-being was improved (P < .001). Our study indicates that indapamide, in addition to blood pressure control, is able to reduce LVH. This effect was achieved mainly through a reduction in wall thicknesses rather than in internal cavity diameter.

Effects of ACE inhibitors or β-blockers in patients treated with the fixed-dose combination of isosorbide dinitrate/hydralazine in the african-american heart failure trial

BackgroundIn the A-HeFT (African-American Heart Failure Trial), treatment of African-American patients with New York Heart Association (NYHA) class III/IV heart failure (HF) with fixed-dose combination (FDC) of isosorbide dinitrate/hydralazine (I/H) reduced mortality and morbidity and improved patient reported functional status compared with standard therapy alone.ObjectiveTo examine the benefit of FDC I/H in subgroups based on baseline drug therapy and to investigate whether ACE inhibitors and/or angiotensin receptor antagonists (angiotensin receptor blockers) [ARBs] or ↓-adrenoceptor antagonists (↓-blockers) provided additional benefit in FDC I/H-treated African-American patients with HF.Study designThe A-HeFT was a double-blind, placebo-controlled study enrolling 1050 patients stabilized on optimal HF therapies and with NYHA class III/IV HF with systolic dysfunction conducted during the years 2001–4 with up to 18 months follow-up. The primary endpoint was a composite of mortality, first HF hospitalization, and improvement of quality of life at 6 months. Secondary endpoints included mortality, hospitalizations, and change in quality of life. Prospective Kaplan-Meier survival analyses were used for differences between FDC I/H and placebo groups and retrospective analyses were conducted within FDC I/H-treated and placebo groups.ResultsSubgroup analysis for mortality, event-free survival (death or first HF hospitalization), and HF hospitalization showed that FDC I/H, compared with placebo, was effective with or without ACE inhibitors or ↓-blockers or other standard medications with all-point estimates favoring the FDC I/H group. Within the placebo-treated group, ↓-blockers or ACE inhibitors and/or ARBs were efficacious in improving survival (hazard ratio [HR] 0.33; p < 0.0001 for ↓-blocker use and HR 0.39; p = 0.01 for ACE inhibitor and/or ARB use). However, within the FDC I/H-treated group, use of ↓-blockers, but not ACE inhibitors and/or ARBs, provided additional significant benefit for survival (HR 0.44; p = 0.029 and HR 0.60; p = 0.34, respectively), event-free survival (HR 0.62; p = 0.034 and HR 0.72; p = 0.29, respectively) and the composite score of death, HF hospitalization and change in quality of life (p = 0.016 and p = 0.13, respectively).ConclusionBased on the analysis of baseline medication use in the A-HeFT, FDC I/H was superior to placebo with or without ↓-blockers or ACE inhibitor. However, ↓-blockers but not ACE inhibitors and/or ARBs provided additional significant benefit in African-Americans with HF treated with FDC I/H. These analyses are hypotheses generating and their confirmation in clinical trials needs to be considered.

Efficacious Response with Lower Dose Indapamide Therapy in the Treatment of Elderly Patients with Mild to Moderate Hypertension

A low dose (1.25 mg) of indapamide (Lozol®, Rhône‐Poulenc Rorer Pharmaceuticals, Collegeville, PA) was evaluated in 222 elderly patients (≥50 years) with mild to moderate essential hypertension in a multicenter, randomized, double‐blind, parallel‐group clinical trial. A 4‐week single‐blind placebo washout period was followed by an 8‐week double‐blind treatment period. Patients were randomized to receive indapamide 1.25 mg/day or to receive placebo. The primary efficacy variable was the mean change in sitting diastolic blood pressure from baseline to week 8. Eighty‐one patients in the indapamide group (73%) and 87 patients in the placebo group (78%) completed the 8 weeks of double‐blind therapy. Therapy with 1.25 mg of indapamide produced greater reductions compared with placebo in sitting diastolic blood pressure after 8 weeks of therapy, with statistical significance (P ≤ 0.0015) seen after only 2 weeks of therapy and continuing throughout the 8 weeks. All secondary efficacy measures (sitting systolic blood pressure, standing systolic and diastolic blood pressures, and ≥ 10 mm Hg decrease or final value of ≤ 90 mm Hg in sitting diastolic blood pressure) also showed superior (P ≤ 0.0014) improvement in the indapamide group compared with placebo after 8 weeks of double‐blind treatment. During the 8‐week double‐blind treatment period, incidence rates for all adverse events and for drug‐related adverse events were similar between the two treatment groups. Among patients who received indapamide, the only drug‐related adverse events that occurred with an incidence of ≥ 2% were headache (4%), dizziness (4%), asthenia (2%), pain (2%), abnormal vision (2%), and impotence (2%). Similar incidence rates for these adverse events were seen in the placebo group. Among indapamide patients, mean changes in potassium (–0.27 mEq/L), uric acid (0.76 mg/dL), and BUN (1.42 mg/dL) were noted but not clinically significant.